RAP schedule forms

Here you can find the forms you may need to prescribe an item under the Rehabilitation Appliances Program (RAP).

Forms

Forms are listed in alphabetical order. Guidelines are available to help you prescribe certain items.

Assistance dog — for psychiatric, guide, hearing and mobility dogs

• D9356 — Request for an assistance dog form

See our guidelines page for more information on how to prescribe an assistance dog

Assistive listening devices

• D9376 — Request for assistive listening devices and/or tinnitus devices form

See our guidelines page for more information on how to prescribe assistive listening devices

Communication devices

• D1382 — Request for assistive communication device and/or speech pathology apps/software form

See our guidelines page for more information on how to prescribe communication devices

Continence

• D0988 — Continence direct order form

See our guidelines page for more information on how to prescribe continence products

Diabetes 

• D9413 - Diabetes Membership Reimbursement
• D9414 - Order Form Diabetes Products

See our guidelines page for more information on how to prescribe diabetes products.

Electric mobility aids

• D9300 — Electric mobility aids — Part 1 — medical assessment form (completed by a general practitioner (GP)/LMO)
• D1325 — Electric mobility aids — Part 2 — assessment form (completed by an occupational therapist (OT))
• D9379 — Electric mobility aids — Part 3 — trial form (completed by an occupational therapist (OT))

See our guidelines page for more information on how to prescribe electric mobility aids

Essential medical equipment

Apply for an annual payment to help with the energy costs of essential medical equipment

• D9400 — Essential Medical Equipment Payment (EMEP)

Home modifications

• D1323 — Authority to install / modify form — home modifications
• D1327 — Complex home / access modifications form
• D9299 — Post home modification report form

See our guidelines page and our Resources for assessing health providers for more information on how to prescribe home modifications

Low vision products (CCTV)

• D9257 — Direct order form RAP low vision products

See our guidelines page for more information on how to prescribe CCTV

Mobility & functional support

• D0992 — Mobility and functional support (MFS) products order form

See our guidelines page for more information on how to prescribe recliner chairs and adjustable electric beds

Non-nutritional thickened fluids

• D9166 — Order form for non-nutritional thickened fluid products

Oxygen and breathing support

• D0804 — Domiciliary Medical Oxygen Therapy (DMOT) and/or Other Respiratory Aids and Appliances form
• D9140 — Application for Positive Airway Pressure (PAP) Equipment form

For more information on how to prescribe see our guidelines:

• Domiciliary Medical Oxygen Therapy (DMOT)
• Positive airway pressure (PAP)

Personal response system (PRS)

• D9199 — Personal Response System (PRS) assessment form

See our guidelines page for more information on how to prescribe PRS

Request / referral for LMO use

• D0904 — DVA request / referral for GP / LMO use

Trial of equipment (exercise bike/knee scooter) - 3 months only

• D9160 — Trial of equipment (exercise bike/knee scooter) form

Vehicle modifications

• D9517 — Driver Assessment and Training / Vehicle Modifications - Medical Information Form
• D9381 — Authority to install / modify form — vehicle modifications

See our guidelines page for more information on how to prescribe vehicle modifications